WASHINGTON—Democrats rode a wave of health care messaging into a majority of the House of Representatives, projections showed Tuesday, propelled by vows to protect Americans with pre-existing health conditions and dramatically lower prescription drug costs.

Some of the winning Democrats highlighted their own health struggles. Others lambasted their Republican opponents for taking money from drug companies and health insurers. The GOP’s steadfast effort to roll back the Affordable Care Act dominated congressional campaigns around the country, and on Election Day, exit polls showed health care was the top concern for voters.

The victory puts Democrats in a far better position to test the far-reaching health care agenda they have campaigned on for well over a year, though their ambitions will almost certainly be curtailed by a Republican-held Senate and President Trump’s White House.

The election leaves Nancy Pelosi in the best position to regain the House speaker’s gavel she held from 2007 to 2011. Pelosi, currently the House minority leader, made health care costs a focus of her party’s “Better Deal” campaign promises in the year preceding the midterms. She told STAT recently that addressing high drug prices will be among the party’s first priorities.

“It’s about stopping the GOP and Mitch McConnell’s assault on Medicare and Medicaid, the Affordable Care Act and the health care of 130 million Americans living with pre-existing medical conditions,” Pelosi said in a speech late Tuesday at the DCCC, referencing the Senate Majority Leader from Kentucky.

“We will take real, very, very strong legislative action to negotiate down the price control of prescription drugs that is burdening seniors and families across America,” she pledged.

Democrats, however, failed to regain control of the Senate, leaving open the question of whether the new House majority can negotiate with McConnell, who has made repealing the Affordable Care Act central to his party’s agenda and is seen as an ally of the pharmaceutical industry.

Then there’s President Trump.

He has been a friend and foe of the biopharma industry, famously accusing drug makers of “getting away with murder” for their exorbitant prices while stocking his administration with industry insiders. The administration has pursued drug pricing plans in fits and starts, with the president’s own aim on the issue scattershot. At times, he’s targeted the middlemen that he says get rich while doing “nothing.” More recently, his administration far more aggressively targeted drug makers themselves in a series of new policy proposals.

Drug pricing could provide an opportunity for Democratic lawmakers to find common ground with a self-described dealmaker president.

Already, some drug pricing hawks have shown a willingness to work with Trump, perhaps best evidenced by a March 2017 meeting at the White House between the president and two Democratic congressmen: Reps. Elijah Cummings (Md.) and Peter Welch (Vt.).

Those lawmakers and others have outlined a legislative agenda to lower drug costs, beginning with a controversial proposal that would fulfill a Trump promise from the 2016 campaign trail: allowing Medicare to negotiate for drug prices.

The White House has shown no signs of following through on Trump’s pledge, but Democrats will attempt to advance it regardless. In the first weeks of the new Congress, Rep. Lloyd Doggett (D-Texas) is expected to introduce a bill not just to enable Medicare negotiation, but to authorize the federal government to award drug licenses to competing companies when manufacturers and Medicare fail to agree on a given medicine’s price.

Those bills and the spectre of a federal “price-gouging enforcer” mirror threats Pelosi made before the pharmaceutical lobby’s top guns in a July meeting, in which she foreshadowed a hostile 2019 for any drug makers that resist Capitol Hill’s proposals to rein in drug prices.

But there are also increasingly powerful Democrats—including many of the lawmakers expected to take key roles on committees overseeing health policy—who are seen as less hostile to the industry.

Rep. Frank Pallone (N.J.), who could helm the Energy and Commerce Committee, often boasts of the biopharma presence in his district. Rep. Anna Eshoo (Calif.), who’s likely to take on a bigger role on the same committee, is among the top recipients of pharmaceutical industry campaign contributions in Congress.

While Democrats at large found health care to be a winning issue, those who campaigned aggressively on insurance and drug pricing issues found mixed results. Sen. Claire McCaskill of Missouri, likely the Democrat speaking most aggressively about taking on the pharmaceutical industry, lost her race in Missouri. Richard Ojeda, a state senator who pledged to bar pharmaceutical lobbyists from his office, lost his House race in West Virginia.

In Florida, however, former health secretary Donna Shalala flipped a seat in Democrats’ favor. In Texas, Republican Rep. Pete Sessions lost to Colin Allred, a Democrat who has campaigned on a promise to authorize Medicare negotiation with drug companies. Sessions was a target of the outside group Patients for Affordable Drugs, which on Tuesday labeled him a “Big Pharma Congressman.”

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